Submitted by Paoli Hospital’s Al Celidonio, director of Pharmacy, and Robert Fried, MD, VP, Medical Affairs
During our recent Joint Commission survey March 8-11, the surveyors found multiple charts with therapeutic duplications. The basic definition of therapeutic duplications is multiple medication orders for the same treatment without distinct instructions for nurses to determine which product to administer. Nursing is not permitted to make this type of judgment. Many of these therapeutic duplications can be remedied by including directions in policy to clarify situations when a patient has the ability to take medications by mouth.
The statements below will be added to both Pharmacy and Nursing policies. Medication orders outside these directions will need defining directions before our pharmacists can validate. See below some examples in RED.
Therapeutic Duplication (addition to policies):
Medication orders with multiple routes. Ordered medications with multiple routes, nursing will use the following instructions:
- IV or PO of the same medication ordered (i.e. Ativan®(lorazepam) 0.5mg IV or PO Q6hrs prn agitation): If patients are unable to take medications orally, then intravenous medication will be used.
- PO or PR(per rectum) of the same medication ordered (i.e. Tylenol®(acetaminophen) 650mg Q4hr PO or PR prn mild pain): If patients are unable to take medications orally, then rectal medication will be used.
- Two separate Medications ordered for same pain assessment with different routes of administration: (i.e. Percocet®(oxycodone 5mg/acetaminophen 325mg) PO Q4hrs prn moderate pain and Dilaudid(hydromorphone )0.5mg IV Q4hrs prn moderate pain) the IV medication will be used until the patient can take oral medication.
- All other therapeutic duplications not meeting the above criteria will be clarified by a pharmacist.
Example Orders that require more directions:
|Toradol®(ketorolac) 30mg IV Q6hrs prn moderate pain and Morphine 2mg IV Q4hrs prn moderate pain||Toradol®(ketorolac) 30mg IV Q6hrs prn moderate pain (may give with morphine) and Morphine 2mg IV Q4hrs prn moderate pain (may give with toradol)|
|Tylenol®(acetaminophen) 650mg Q4hrs prn mild pain and Motrin®(ibuprofen) 400mg Q4hrs prn mild pain||Tylenol®(acetaminophen) 650mg Q4hrs prn mild pain and Motrin®(ibuprofen) 400mg Q4hrs prn mild pain unrelieved by Tylenol®(acetaminophen)|